Rural and Urban Home Modification Program Users: A Comparative Study.

OBJECTIVE: To understand the sociodemographic, geographical, and clinical characteristics of rural veterans utilizing home modification (HM) healthcare services under the Home Improvement Structural Alterations (HISA) program, to compare these characteristics between rural and urban veteran users, to estimate the costs of HMs performed, and to present distance that users traveled to HISA-prescribing medical facilities within the Veterans Health Administration (VHA). BACKGROUND: Accessible housing is in short supply. HMs allow veterans with disabilities (VWDs) to remain living at home rather than enter institutional-type settings. HISA is associated with decreased inpatient hospitalization rates and increased use of preventative healthcare via outpatient clinic visits. Home accessibility provides psychological benefits improving social interactions and interaction with the physical environment. METHODS: This retrospective database study analyzes data from the National Prosthetics Patient Database and other medical datasets within the VHA. RESULTS: Results provide a profile of and comparison between rural and urban veteran users. HISA users are substantially older compared to younger VWDs. The frequency of bathroom, railing, and wooden ramp HMs differed significantly between rural and urban users (p values < .001). Rural users traveled more miles than urban users to reach a prescribing facility. CONCLUSIONS: Older adults and individuals with disabilities have unmet housing needs since accessible housing is in short supply. This HM healthcare service is helping to meet the housing accessibility needs of older veterans, VWDs, older adults, and people with disabilities, in general.

Predictors of County-Level Home Modification Use Across the US.

Background: Geospatial analyses illustrating where the Home Improvements and Structural Alterations program (HISA) have been prescribed suggest that home modification (HM) services under US Department of Veterans Affairs (VA) is not prescribed and used uniformly across the US. Methods: The objective of this study was to identify county characteristics associated with HISA use rates, such as county-level measures of clinical care and quality of care, variables related to physical environment, and sociodemographic characteristics. Multiple regression analysis was used to predict county-level utilization rate from county-level variables. Results: County-level HISA use was highly skewed and ranged from 0.09 to 59.7%, with a mean of 6.6% and median of 5%. Percent uninsured adults and rate of preventable hospital stays emerged as significant predictors of county-level HISA utilization rate. Specifically, county percentage of uninsured adults was negatively related to county-level HISA utilization rate (b = -8.99, P = .005). The higher the proportion of uninsured adults the lower the HISA utilization rate. The county rate of preventable hospital stays was positively related to county-level HISA utilization rate (b = .0004, P = .009). County-level predictors of housing quality were not significantly associated with county-level HISA utilization rate. Conclusions: Our research fills a gap in the literature about the impact of county-level variables and the geographic distribution and use of HISA. More research is needed to understand and account for geographical variation in HISA use. This work serves as a first step at quantifying and predicting HISA utilization rate at a broad level, with the goal of increasing access to HMs for veterans with disabilities.

Home Modifications for Rural Veterans With Disabilities.

BACKGROUND: Appropriate home modifications (HMs) can make the home environment accessible and relatively safe by reducing the risk of falls. Of special concern are individuals living alone, living in rural communities, and/or living in substandard housing. The Home Improvements and Structural Alterations (HISA) is a Veterans Health Administration (VHA) benefit program providing HMs for veterans with disabilities. METHODS: The objective of this study was to detail the profile of rural veteran (RV) HISA users and report on national HISA utilization patterns. We compare use at US Department of Veterans Affairs (VA) medical centers of varying complexity levels, and in VA regions. An examination of the relationship between travel time/distance and HISA utilization is also provided. This retrospective database study uses GeoSpatial analyses and 3 VA sources: The National Prosthetics Patient Database, the VHA Medical Inpatient Dataset, and the VHA Outpatient Dataset. RESULTS: From 2015 through 2018, 10,810 RVs used HISA with a mean age of 70.9 years. A majority of participants were White (79.5%), married (74.3%), and male (96.5%) veterans. They traveled a mean of 79.8 miles for 94.5 minutes to reach a facility where they received a HISA prescription. Nearly 75% of HISA users were able to receive a HISA prescription from their nearest facility, while about one-quarter traveled to a facility farther away, of which 43% travelled between 100 and 200 miles to obtain the HISA benefit. The top categories of diagnoses were musculoskeletal (19.1%), neurologic (12.5%), and cardiovascular (5.4%). There were about 11,166 HM prescriptions afforded to rural HISA users during the period, including bathroom (82.4%), doorway (4.9%), and railing (3.6%) modifications. CONCLUSIONS: This study documents the national demographics and clinical characteristics of rural HISA users, data that may be useful to policy makers, HM service providers and advocate as well as HISA administrators in predicting future use and users.

Geographic Variation in Initiation of Evidence-based Psychotherapy Among Veterans With PTSD.

INTRODUCTION: The United States Department of Veterans Affairs (VA) has invested in implementation of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD) for over a decade, resulting in slow but steady uptake of these treatments nationally. However, no prior research has investigated the geographic variation in initiation of EBP. Our objectives were to determine whether there is geographic variation in the initiation of EBP for PTSD in the VA and to identify patient and clinic factors associated with EBP initiation. MATERIALS AND METHODS: We identified VA patients with PTSD who had not received EBP as of January 2016 (N = 946,667) using retrospective electronic medical records data and determined whether they initiated EBP by December 2017. We illustrated geographic variation in EBP initiation using national and regional maps. Using multivariate logistic regression, we determined patient, regional, and nearest VA facility predictors of initiating treatment. This study was approved by the Veterans Institutional Review Board of Northern New England. RESULTS: Nationally, 4.8% (n = 45,895) initiated EBP from 2016 to 2017, and there was geographic variation, ranging from none to almost 30% at the 3-digit ZIP code level. The strongest patient predictors of EBP initiation were the negative predictor of being older than 65 years (OR = 0.47; 95% CI, 0.45-0.49) and the positive predictor of reporting military-related sexual trauma (OR = 1.96; 95% CI, 1.90-2.03). The strongest regional predictors of EBP initiation were the negative predictor of living in the Northeast (OR = 0.89; 95% CI, 0.86-0.92) and the positive predictor of living in the Midwest (OR = 1.47; 95% CI, 1.44-1.51). The only nearest VA facility predictor of EBP initiation was the positive predictor of whether the facility was a VA Medical Center with a specialized PTSD clinic (OR = 1.23; 95% CI, 1.20-1.26). CONCLUSION: Although less than 5% of VA patients with PTSD initiated EBP, there was regional variation. Patient factors, region of residence, and nearest VA facility characteristics were all associated with whether patients initiated EBP. Strengths of this study include the use of national longitudinal data, while weaknesses include the potential for misclassification of PTSD diagnoses as well as the potential for misidentification of EBP. Our work indicates geographic areas where access to EBP for PTSD may be poor and can help target work improving access. Future studies should also assess completion of EBP for PTSD and related symptomatic and functional outcomes across geographic areas.

Postacute stroke rehabilitation utilization: are there differences between rural-urban patients and taxonomies?

PURPOSE: To assess the association between Veterans affairs (VA) stroke patients' poststroke rehabilitation utilization and their residential settings by using 2 common rural-urban taxonomies. METHODS: This retrospective study included all VA stroke inpatients in 2001 and 2002. Rehabilitation utilization referred to rehabilitation therapy received 12-months poststroke hospitalization. Patients' urban, rural, or isolated/highly rural status was determined using the rural-urban commuting areas (RUCA) and VA rural urban (VARU) definitions based on patient residential ZIP code. Logistic regression models were fit for the rehabilitation outcome, adjusting for potential risk factors. FINDINGS: Among the 8,296 stroke patients, 69.6%/61.1% were categorized as urban, 21.3%/37.5% as rural, and 9.1%/1.4% as isolated/highly rural by the RUCA/VARU definitions, respectively. Compared with their urban counterparts, the rural and/or isolated/highly rural patients were significantly more likely to be older, white, married, living further from the VA hospitals, not hospitalized for stroke directly from home, and not intubated. Compared with the rural patients, odds of receiving rehabilitation therapy were 1.2 times (RUCA) and 1.1 times (VARU) by the urban patients, and 0.53 times (VARU only) by the highly rural patients, after risk adjustment. The above comparisons were significant at P < .05. CONCLUSIONS: With both taxonomies, the rural patients were less likely to receive postacute stroke rehabilitant therapy than their urban counterparts. With the VARU, the highly rural patients were less likely to receive rehabilitation care than their rural counterparts. Different taxonomy may lead to different rural-urban classification yields and different yields may lead to different outcomes and conclusions.

The effects of the Health Insurance Portability and Accountability Act privacy rule on influenza research using geographical information systems.

The Health Insurance Portability and Accountability Act (HIPAA) privacy rule was enacted to protect patients' personal health information from undue disclosure. Despite its intention to protect patients, recent reports suggest that HIPAA restrictions may be negatively impacting health research. Quantitative, visual geographical and statistical analysis of zip code geographical information systems (GIS) mapping, comparing 3-digit HIPAA-compliant and 5-digit HIPAA-non-compliant simulated data, was chosen to identify and describe the type of distortion that may result. It was found that unmitigated HIPAA compliance with HIPAA mapping rules distorted the GIS zip code data by 28% leading to erroneous results. Thus, compliance with HIPAA privacy rule when mapping may lead investigators to publish erroneous GIS maps.

Using geographic information system tools to improve access to MS specialty care in Veterans Health Administration.

Access to appropriate and timely healthcare is critical to the overall health and well-being of patients with chronic diseases. In this study, we used geographic information system (GIS) tools to map Veterans Health Administration (VHA) patients with multiple sclerosis (MS) and their access to MS specialty care. We created six travel-time bands around VHA facilities with MS specialty care and calculated the number of VHA patients with MS who resided in each time band and the number of patients who lived more than 2 hours from the nearest specialty clinic in fiscal year 2007. We demonstrate the utility of using GIS tools in decision-making by providing three examples of how patients' access to care is affected when additional specialty clinics are added. The mapping technique used in this study provides a powerful and valuable tool for policy and planning personnel who are evaluating how to address underserved populations and areas within the VHA healthcare system.